Two Peaks in a Pod

The Hidden Fertility Factors That IUI (Intrauterine Insemination) can Overcome.

• Beverly Reed • Season 3 • Episode 1

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Dr. Amber Klimczak and Dr. Beverly Reed discuss how adding IUI (intrauterine insemination) can overcome multiple fertility issues from many different mechanisms of action. Watch this (Season 3, Episode 1) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Links are in @drhappyeggs IG bio.

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Clack. And we are two peaks in a pod. Well, hi everybody. Welcome back. Dr. K. Yes. It feels good to be back. We, I A little hiatus. Yeah. We took a summer break. Yeah. But during summer break, something different happened with you. Do you wanna tell everybody? Yeah. So. Deliver The baby Summer was good. It was actually Rainbow Baby for us. Oh. Um, someone told me, I think Rainbow Baby Day, right? Yes, yes. This week. This week, yeah. So that was kind sweet to take it out. Um, as a reminder, you know, once you're. At the success point of your story. Yes. It's nice to look back sometimes on what you went through. Yes. Well, we definitely miss you When you were gone, um, when we told people you were on maternity leave, they said she was pregnant, so you really slid under the radar there. That was pretty good. Some big. Scrub. Yeah. And they said, oh, she must have had a really tiny baby. And I'm like, Nope, he's a big baby. He's a big baby. Tell them how much. Yeah. Seven pounds, 10 ounces. Where were you hiding him? He's huge. He had already 11 pounds. Oh my gosh. So, wow. Wow. Okay. Well, I wanted to tell you about a patient that I saw whenever you were gone. And my heart really went out to her. She, she came to me. She was really stressed. She had come from another practice. You know how we always say, we call ourselves the place you go to when you're mad at your first clinic? Yeah. And so she had come from another clinic and she said, look, um, Dr. Reed, I have been diagnosed with having low ovarian reserved. Have low egg counts. Um, I only want to have one baby. Um, but my doctor was really pushing me to do IVF and it just, I didn't feel right about it. I wasn't ready for it. It just felt more than I wanted to do, you know? And so I wanted to get a second opinion. Do I have to do IVF? Um, and are, is there anything else I can try? And I said, you came to the right person because Absolutely. There's so many other things that we can try and especially when it comes to low egg counts, I think that's one of our biggest pet peeves is sometimes a low A MH is seen a low egg count. Yeah. And that has just been, um, the driver to force somebody into to IVF. But we know that just because you have a low A MH, you still have the same chances of getting pregnant on your own. Same chances of getting pregnant with IUI treatment. Um, and while there may be other reasons to do IVF like fertility preservation for the future or things like that, it doesn't always necessitate going to IVF. Have you seen any second opinion counsels like that too? Yeah, absolutely. Yeah. Um, you know, I think it really stems from Okay, are there benefits to doing IVF initially, right? Yeah. Um, present and want to do fertility treatment in general. Yeah, IVF of course is our most effective treatment option. True. It's going, going to have the highest success rates and the quickest route to pregnancy, so there are certainly benefits to it. So we can understand why your doctor might offer you IVF in that circumstance and. You never wanna go back and say, why did you tell me I could have done IVF, right? Mm-hmm. We never wanna be in that circumstance, but it doesn't mean it's the only option. 100%. Yeah. So anyway, so I start seeing this patient and um, you know, I do an ultrasound on her and I give her some fertility pills and she responds so nicely to the fertility pills on the follow-up ultrasound. And I say, okay, let's do an IUI. She says, oh, I don't wanna do an IUI. And I'm like, oh no. I said, okay, well here I was like your nice natural doctor telling you didn't telling you you didn't need to do IVF. But I'm like, let me explain to you why IUI is helpful and this is probably one of the most common questions I will get.'cause people will say, why can't I just take fertility pills? Why do I need to do IUI? Is this something that comes up for you too? Yes, absolutely. Mm-hmm. And I would say, as you know, just. Kind of tuning in to understand what patient population we're talking about. This is really kind of addressing the unexplained infertility population. Yes. Even though this patient has low egg reserve, right. This is really the studies and the data that's looking at patients who don't have a ovulation disorder or don't have a problem with male factors, sperm disorder. Why do you need to add in an IUI when you're taking fertility pills? I think that's kind of the answer to this. Such a good point because a lot of times our patients are friends with each other and so they'll say, well, Dr. Reed, you saw my friend Susie. And you told her all she needed was fertility pills, but now you're telling me I need fertility pills and IUI. So what's the difference there? Well, her friend Susie was not ovulating. How did I know that? Well, she didn't have period. She would go six months without having a period when you're not having periods. You are not ovulating regularly. And so that becomes a very obvious cause of the fertility issues. And I know we can give you fertility, pills, help you to ovulate an egg, and data backs us up that that is going to give you a very good chance of getting pregnant. But that's very different from somebody who's already ovulating. How do I know if somebody's ovulating, if they're having a regular period every single month? We know 95% of those women are already ovulating. And so I say, look, if you take the average person who's been maybe trying for a year, that means if you look back, that patient has ovulated 12 eggs. And she's not pregnant. And these are circumstances in which you've checked her fallopian tubes and they're open and you've checked the sperm and it's normal. So then you have to ask yourself, why are they not getting pregnant? Could it be something else going on? And that's what IUI can really help us with. And so what I ended up doing is explaining to the patient, Hey. When I look at your history, I can see you're ovulating on your own. I don't feel like I'm helping you enough with fertility pills. Can fertility pills help you grow extra eggs in a month? Sure. Instead of growing one egg, maybe you'll grow two or three eggs in a month, but you've already grown 12 eggs before and it didn't work. So why would I think that would help or change anything? Let me boost your chances by just adding on a simple little insemination procedure. Absolutely. Yeah. And you know, one of the other sort of downfalls of using certain fertility medications, like the most common one that we use for a patient like this is probably Lumin, right? Mm-hmm. Mm-hmm. Um, is as a side effect, it can affect the cervical mucus. And so we know from studies that if you don't pair it with Inseminations to bypass that cervical mucus, we can kind of be showing ourself in the foot from the other side. So, um, that's why even sometimes this conversation is important before we get going on Clomid, right? Yes. So that we can, uh, make sure we're on the same page when it comes time to do an IUI because it really should be paired with an IUI, especially for this patient population where we're trying to. Increase your fertility above that, you know, natural baseline. Absolutely. And I really love a review. I saw where they compared four groups, so they had a group that decided to just keep trying on their own. Right. Even in somebody with infertility. It doesn't mean you can't get pregnant, it's just you get pregnant with lower efficiency when compared to somebody else. So in general, we think an infertile person probably has about a 5% chance of getting pregnant every month. Okay. So they had a study group that just kept trying on their own. They had a study group that did clo. They had a study group that actually did IUI, but no fertility pills. And what they found is all three of those groups had the same chances of getting pregnant. And so fertility pills didn't help. IUI didn't help. And it was only the fourth treatment group. That did both Clomid and IUI that had triple the chances of any of those other groups, which is amazing. And I think when I tried to understand why that would be, that really kind of circles back to what you were just pointing out. Clomid is great at stimulating the ovaries, but sometimes there's some side effects that can actually work against your fertility. But then when you're pairing that with the insemination, you're able to bypass the side effect, and that's probably why you get the synergistic effect of both, um, c Clomid and IUI together. Yeah, definitely. Yeah. Um, and I think people hear a lot about Clomid and mm-hmm. You're familiar with Clomid when you come into a fertility doctor and I, UIs aren't as talked about. And so it is important to know that it's. Ideal for certain patient populations for those to work synergistically? Mm-hmm. Absolutely. Absolutely. So maybe I'll grab my little model here. So I know if you're listening on the podcast, you can't see our model, but if you're on YouTube you can see it. So we've got my uterus here now. My poor uterus has a lot of things wrong with it. You can see polyps and fibroids and endometriosis and everything. But the whole point is just to kind of show you how the IUI works here, and so I've got a little IUI catheter here and I think the first thing that really surprises people is how. Tiny and gentle. It is, yes. I call it like a little spaghetti noodle. Yeah. Right. It's, it's harmless. It's not gonna hurt anything. Yeah. Because sometimes people feel scared it, to them it feels like a procedure, and so they come in thinking, oh gosh, what is she gonna do to me? But no, it's just a harmless little tube like that. There's nothing sharp. Nothing sharp. Yeah, no needles. I think that's like one of the most important things to understand. Yeah, yeah. About an IUI.'cause anytime someone thinks about getting some sort of procedure done, I worry about anything being sharp. Yes. Yes. Okay. So maybe can you, let's see. Can you help? You're gonna do the IUI. Okay. So let me just show you. This is the vagina right here. So if you are having intercourse, the sperm would be starting off here. But what Dr. K is gonna do is introduce that little tube. Through the vagina and then through the cervix here. Polyps. Yeah. And then right into the uterus right here. Okay. Now there are some important distinctions to make.'cause sometimes people will say, well, can you get it in the fallopian tube? Well, it's, it is, it's tiny, but it's still too big to fit in a fallopian tube. So it just goes here into the uterus, and then the sperm are still gonna have to swim through the tubes to reach the eggs. Um. And then let's see what else. Sometimes people, um, will also ask, is there anything you can do to get the sperm to go to one side or the other? Mm-hmm. Because when we're doing ultrasound, sometimes we'll say, oh, your eggs grew on the right or Your eggs grew on the left or something. But what I think is fascinating is, um, they did this study where I'm surprised they could do this study really, but they did an insemination on women who are about to have a hysterectomy so that they could see where this sperm went. Yes. So insemination, hysterectomy, they looked well. What they found is the sperm did go to the side where the egg was. And so we think that's because an egg probably releases a chemo attractant that sperm can sense. And so since they knew where to go, that's what I kind of reassured patients, Hey, we put'em as close as we can and then they should know where to go from there. Yeah. Yeah. Your body knows what it's doing. Yes. Yes. Um, okay. So it's really just as simple as that. Um, but now let's kind of just break down specifically how IUI can be helpful. And I think this is so important because I've heard from many patients that sometimes your doctor will say, oh, do IUI? But they don't really explain to you why it can be helpful. And I know for me as a patient, I need to know those details so I can make an informed decision about whether I want to try something. Mm-hmm. I do feel like the most obvious reason to do an insemination is if there's some kind of sperm problem, right? Absolutely. Yeah. And some of these sperm problems, it's really, you know, obvious as to how it's gonna help too. Yeah. Right. So when we get the semen analysis results back, and maybe your partner has. Low motility. That's the ability of the sperm to swim and progressive motil swim forward. You can see how if we bypass so much of that vagina and cervix and get sperm up closer to the egg, it's gonna be a lot easier for egg and sperm to get together if they're not so good at swimming. Mm-hmm. And swimming forward. Mm-hmm. So that's a pretty, you know, obvious reason why the other part of the IUI that we haven't really talked about is that we actually prep the sperm. Mm-hmm. We wash it, we concentrate it. Right? So we improve these parameters. So if someone has low sperm numbers, sperm counts, or what we call low concentration or oligospermia, this is a great treatment because we are going to concentrate that sperm and then also. Bypass so much of that attrition or the loss of sperm that's happening in the vagina and at the level of the cervix and putting it right at the top of the uterus to make it easy for that lower sperm count guy to get his sperm to the egg. So motility, ability to swim, concentration issues, those are really obvious reasons why we would consider an IUI. Yeah, and even from a patient perspective, you may be able to pick up on some of these things at home, I guess, depending on how much you see and a bit. But what I mean by that is sometimes if you just look at the semen, the semen can have all different types of consistencies, right? There are some men that, for whatever reason, have a very. Thick gelatinous semen. And to me, I picture myself as a little sperm trying to swim through jello essentially, and I'm like, I can definitely see how this could cause an issue or problem. But when you're doing an insemination and we're washing the sperm, we get rid of all that thick, viscous semen and we're really just, um, allowing the sperm to have an easier vehicle to swim through, essentially to get, to get to where they need to go. And then, you know, one of my side hobbies is immunology too. And so one of the things that sometimes people think about is could there be antibodies, um, that could be sticking to sperm and slowing them down and everything. And so maybe for some people, if we don't know this issue is going on, maybe, um, washing the sperm can help address that and. Free up some of those sperm to have a better chance at, at getting to where they need to go. Um, but I think this also brings up an important safety point. Um, sometimes there's some do it yourselfers at home, gosh, but it is very important to have the sperm washed if you're gonna be injecting it into the uterus. Okay. Now, gosh, it took us a long time to be able to train and learn how to find the cervix and everything, so it always surprises me when some people are trying this type of thing at home, but I would not recommend that. Yeah. Um. But, um, these days I've heard of little, you know, syringe kits and things like that you can do at home. Oftentimes they're talking about just putting it into the vagina. Okay, fine. But you don't wanna put unwashed sperm into the uterus because. Semen has prostaglandins in there. Okay. Now, since the semen usually starts off in the vagina, it's only the sperm that are typically swimming up. But if you take that semen and put it directly into the uterus, that is actually a safety issue. You can even end up having to go to the ER or something because those prostaglandins cause lots of pain and inflammation and problems like that. So that is definitely a big no no. Right. So, you know, if you're at home Yeah. Having intercourse or you're placing semen in the vagina Yeah. Your cervix actually acts to wash the sperm, you know? Yeah. Mm-hmm. Um, so there's lots of d and cranies or really channels going through the cervix that sperm have to make it up through in order to enter the uterine cavity. Um, and so if you're bypassing that sort of cleansing process, that's where you can get yourself into. Some dangerous trouble. Yeah, yeah. Now, although IUI can be helpful for patients that have low sperm counts, there is kind of a point to where you probably do need to consider IVF, right? Yeah. So one of the common calculations many of us will use is calculating what is the total modal sperm count. In other words, you're taking your semen analysis results. You're taking the volume and multiplying it by the concentration and then multiplying it by the motility and move the decimal over. Mm-hmm. And that is what gives you your total modal count. And we use those numbers to try to just help prepare a patient to let them know, Hey, do we think you have a good or reasonable chance that IUI is gonna work for you? Or is that total modal count just so low that maybe we do need to consider? Um, moving on to IVF instead. Right. Yeah. That's the number. I think, um, especially with my male patients. Mm-hmm. Really respond to hearing what their number is and what level they sit at. And we kind of have three levels that I counsel my patients. I say, okay, if you're above this, then it is reasonable to use time intercourse as your treatment. Then you drop below that and maybe intrauterine insemination is a really good treatment option for you, but if it drops so low, then you're really saying to them, even though it's not a 0% chance that you can get pregnant with an IUI or on your own, it really is an IVF specimen that we're looking at because with IVF, we can use such smaller numbers of sperm and have. Yeah, absolutely. And we would never tell anybody it's impossible to get pregnant at a certain sperm level. But again, it's with what efficiency. Right? Right. I always see those people on tv. My doctor said I couldn't get pregnant, and here I'm, and I'm like, who's this doctor telling everybody they can't get pregnant? Like I, I mean, you could have had a hysterectomy. I'm still not gonna tell you can't get pregnant. Like, there are crazy things that I've seen some crazy case reports and everything too. So, um, okay, good. So next I wanted to talk about. Vaginal factor and the, so really the next two things we're gonna talk about, vaginal factor and cervical factor do not get talked about a lot, but I think they're really important. So if you're just having intercourse on your own, the semen and the sperm, they start off in the vagina. But the vagina's a really harsh environment for sperm to survive in. And in fact, sperm can typically only live in the vagina for one hour because of the pH. And, but of course, all my patients, and this is a smart question, I think, say, okay, well if that's true, what if I just changed the pH in my vagina? I've actually never had a patient say that. Oh, mine, mine are very, I'm like, yeah. But, um, because here's the thing, the pH of the uterus is different. The uterus is so much more friendly to sperm, and studies have shown sperm can just be swimming around in the uterus for up to five days. And so that's why people say, well, I'll just change the vaginal pH. And I say, oh my gosh, don't do that. Because it's important to have a really harsh vaginal pH. That is what keeps our vagina healthy, right. How are you suggesting they change the pH with like some yogurts or like what? Yeah, probably. Yeah. Yeah. I mean there's all types of things online these days. Oh gosh. But, um, that harsh pH is what kills off bad bacteria, right? So we want you to have a vagina with a harsh pH because that's gonna help you keep a healthy vagina. And I worry if you try to change your own pH of your vagina, that you're gonna get infections. You know? Yeah. So I think you could get bacterial vaginosis or really any other type of infection as well. So don't try to do it yourself on that one. And, but, but how is the, what's the benefit then? Well, if we are bypassing the vagina completely, using our little insemination to, to get the sperm to the more favorable environment, then for some people that's gonna help. The reason I think it doesn't get talked about a lot is, you know, people really want a diagnosis. They want somebody, for example, to come say, your problem is vaginal factor. Right? But we don't really have a way to diagnose that. We just know in general that the vaginal has, or that the vaginal area has a harsh pH. And so, because there's not really a way to assess for that and assign that diagnosis, I think that's why maybe it doesn't get talked about as much. Yeah. And you know, these are tests that. People really used to look into 40, 50 years ago. That's true. When they have such advanced technology. That's true. We have to just. Bypass these, right? Mm-hmm. So our treatment options, like IUI and IVF very quickly correct these sort of factors. Mm-hmm. Um, but there was a, there were a lot of men back in the day that really looked into this. That's true. So it can be studies, it's just not a common, these are common tests that we're doing all the time. Yeah. Yeah. Absolutely. Okay. So that is gonna kind of take us to cervical factor. I'm kind of thinking we can divide cervical factor into maybe like cervical mucus and then the cervix itself. Mm-hmm. The fact that you mentioned that, like Pat, do you remember, have you heard about the post-coital test back way back then? Oh yeah. I mean this is interesting, right? Yeah. Um, that used to be one of the old tests is I guess you would have intercourse and then the doctor would wanna take some of your mucus. To, I guess look at the sperm swimming through your muca mucus, and then make some assumptions about that. But it, it turned out that wasn't really proven to be very helpful. Right? Yeah, yeah. Yeah. And it's not gonna change our management, as you know. Yeah. In, in modern treatment. Yeah. I think really we're just like, well just bypass it. Just do IUI. Right. Um, but, uh, the first thing I just wanted to mention with the cervix, and I accidentally offended somebody the other day, um, one of the guys. Because, okay, I'm, I'm getting ready to do the insemination. I've got my speculum in there. And her cervix was so high up, okay? I had to get the long speculum. And even with the long speculum, I can barely reach it. I'm like, oh my goodness. And so I said, well, no wonder y'all are having trouble getting pregnant. Your cervix is so high. How can anybody reach this? And I think he thought that was me saying. Something about his manhood and he said, I'm just fine. Thank you very much. And I said, oh, no, no, sorry. I wasn't meaning that at all. But I do feel like in models and textbooks, they always show the cervix like it's right in the middle. Yeah. But I mean, they can end up in some tricky spots. Right? Absolutely. Tucked up and you know, sometimes even. Um, we can see this with secondary infertility, like I've seen after c-sections when, you know, the way they're closed, like it pulls the cervix way up. Mm-hmm. Very difficult for me to access. It's in a totally different place than it was previously. Yeah. Yeah. So deviate. For YouTubers, I'll try to show you. So let's say this is the cervix and let's say this is penis, right? So usually you would think it would be right on, right? But the cervix can be, she was talking about if you had a C-section. Sometimes it's like this, your cervix is essentially facing the ceiling. Well, that obviously makes it really difficult or I've seen it down. Or I've even seen it flipped back like that. And so you're like, well, of course, um, that's gonna be an issue. But the problem is that may not be apparent on an ultrasound. Um, and on an exam, sometimes you're just going in there to do the exam. You may not be really thinking about it at the moment of, Hey, maybe this is a cause for fertility issues. Um, so again, I feel like this is an. Under-recognized fertility factor, this cervical factor, um, that people don't really get a chance to really know and understand that that could be causing their issues. Yeah, and especially too, I think it's important when you mention C-section, right? This might be a person who got pregnant easily before. Mm-hmm. Now they're not and they don't know why. But as you're mentioning, it might just be a little bit of scar tissue is putting the cervix in a position that is different and more difficult to get to. Yes, absolutely. Yeah. Yeah. Um, okay, let's. Also talk about the cervical mucus. Alright, so for women who are very in touch with their bodies, oftentimes as you get close to ovulation, you start getting clear, stretchy, vaginal discharge. This is totally normal and it's a good thing. It usually means your estrogen levels are nice and high at that moment. So that's what should happen. But sometimes we get patients who say, no, I checked for that. I never had that. True. Yeah. And I don't, why, why would a woman not make discharge? Sometimes we don't know. I mean, of course it could be that you're not growing a follicle, you're not making the right hormones. But in someone where every, where, all that all looks good, sometimes we just don't know why they're not making that favorable discharge. But I can certainly understand how it's harder for the sperm to get through if they don't have that discharge to kind of help. Help them along the way. Right? Yeah. Having that, that discharge present is essential. So it really triggers, um, cervical mucus and discharge that doesn't allow sperm to get through the cervix, and then it changes completely. Mm-hmm. Once you have these high estrogen and what Dr. Reed said is really important, I think a lot of people don't understand this. This happens before. You ovulate, right? Mm-hmm. So remember, we always tell our patients have intercourse before ovulation. Mm-hmm. So, tracking your cervical mucus can be extremely helpful.'cause once you see that shift, you're probably gonna ovulate, you know, a couple days after that, right? Mm-hmm. So a lot of people say, well, I'm ovulating. We cervical mucus change. They're really panic that we miss ovulation, or something like that. Yeah, no, it's a good sign. Yeah. It's going, your circle mucus is chaining.'cause your estrogen is high and you're going to ovulate soon. Yeah. It doesn't mean that you have already ovulated. Mm-hmm. Absolutely. Yep. Now I will say just this is a shout out for our IVF patients'cause I just got this portal message today. Mm-hmm. If you're doing IVF and you have lots of clear stretchy discharge, don't worry. That's just'cause your estrogen levels are higher than normal, it doesn't mean you're about to ovulate. Yeah. Um, in general we usually are managing that differently, but yes, for our, for our IUI patients, that's absolutely the case. And then as Dr. K had mentioned earlier, remember if you're on CH Clomid or certain fertility medications. It may thin out that discharge. So how does IUI help you then? Well, if you usually have discharge here, and it's usually helpful to the sperm, but you either don't make favorable discharge'cause you have some sort of issue on your own, or you're taking fertility medication that's affecting your discharge, then just bypassing that area, getting the sperm straight into the uterus is gonna take away that factor that would normally potentially lower your chances of getting pregnant too. Um, okay. Now I wanna go back to the cervix again because we talked about position of the cervix. We talked about cervical discharge, but the cervical canal. Yes. Woo. Okay. Or the opening. The opening to the cervix Yeah. Is very interesting. Um, because this is where text. Books and models always do us wrong because they always show the cervix like a straight tube. Mm-hmm. Don't you wish it was like that every single time? Yeah. That would be. We've probably taken years off of our lives trying to get into some of these C Oh my gosh. Our jobs would be so much easier. And the thing is, we can never tell ahead of time what somebody's cervix is gonna be like. I will tell you, 90% of the time you put that tube in and it goes right in. Mm-hmm. But woo. There are some times where getting through the cervix is like hitting a brick wall. Yeah. And even on the same person. Yeah. On a different day. That's true. Yes. Yeah. It's just, yeah. It really is strange how it can change. Um, but you know, what we're referring to really is the cervical opening. Mm-hmm. Something's called the oz. Right. It's like, if you imagine a donut, it's like the little part where the donut hole. Right. Mm-hmm. Would come out. So it's the opening. Mm-hmm. Um, and it leads to a little canal and goes up to the uterus. Obviously sperm has to pass through this in order to, you know, get you successfully pregnant. And you can have a lot of reasons why this is not super straightforward. So, um. You know, nowadays we're really good with our cervical cancer screening, right? So some people may have had procedures done to their cervix. Maybe if you've had an abnormal pap sear in the past, you've had a leap procedure or a cone procedure, um, where they take off a small piece of your cervix that can lead to some. Scarring and, and we call that cervical stenosis or narrowing of the actual opening. And um, that can really make it difficult to get through your cervix and probably even affect some of the glands and things that are producing mucus. So there can kind of be two ways that it's affecting things. Um, but you know, we hypothesize that that's probably affecting sperm, right? If we're having a really hard time getting through then. Probably this sperm is as well. So you could have had a procedure, you could just be born that way. You know, some people just have a really small cervical opening cervical canal. Um, or it can be very unusually shaped. You know, what Dr. Reed's alluding to is sometimes they're just like these windy year corks group paths. Mm-hmm. Even going through not just this very straight shot through. Um, and you can imagine that's really hard for sperm to navigate sperm or having to do like some gymnastics. Skin. Yeah. Yeah. And I mean, what's crazy to me too is, you know, sometimes it can be kinked like this. And think of a garden hose that's kinked, the water's not gonna get through. Well, imagine if you have a kinked cervix, the sperms not gonna get through. Um, but as she was alluding to sometimes too. It can vary by the day. Yeah. So one Dr. May say, and it's always hard too, when you're that doctor who struggled and then the next doctor comes in and it's easy and you're like, Hey, like, lemme explain. Right? Yeah. Because sometimes, for example, your bladder sits right on top of you, right? So. Maybe can you put your hand as the bladder? Yeah. Okay. So as the bladder fills up, it can straighten out that kink sometimes. So that can sometimes make it a lot easier when, maybe on a different day. It was really difficult too. Um, it's, and it's not always the same for all patients. Some patients it's easier with an empty bladder. That's true. It's easier, the full bladder. Yes. Um, and it just depends. And sometimes a full bladder can work against you too, if it's two full, like it's, it's a difficult situation sometimes. But ultimately, here's what I tell patient. If you are really seeing me struggle with your cervix, it's a good thing because you're probably the person that's gonna help the most, right? Right. Mm-hmm. Um, and, and so that's what I think this is really kind of underestimated how important cervical factor is for, um, fertility. Now, just kind of another thing that I think about if I see a very narrow or kinked cervix or something like that, I also think. Could this patient be at higher risk for having endometriosis? So endometriosis is a condition where when you have your period, it backflows through your fallopian tubes and implants in the um, near the ovaries. The tubes in the pelvis, and it can create inflammation, infertility problems. But to me it makes a lot of sense if your cervix is so narrow. That menstrual blood struggles to come out and it backflows, okay? You can put the pieces together and determine those things may be linked together as well. So I feel like you can get a lot of information even from doing an IUI. Yeah. Even if you don't get pregnant, and I did an IUI on you and I really struggled. I'm writing that down in your chart of like, Hey, I think there's some cervical factor here. These are some other things that I need to be thinking about too. So I really always like that concept of when you're doing a treatment cycle with us, we're trying to get you pregnant, but we're also learning more about your body as we go along too. Um, okay, so we talked about male factors. We talked about vaginal factors, cervical factors, and then there's a group of patients too that need help with an insemination. So let's, uh, take a minute to talk about maybe single mothers by choice and same sex couples and everything too. Um, to just kind of talk about how IUI can be helpful for them as well. Yeah, so I mean. With same-sex couples or women who are opting to, um, do an IUI themselves, right? They're missing sperm obviously. So oftentimes you'll order donor sperm, um, from a bank or from a known donor that you know. Um, and while some people might opt to do home inseminations, we have a lot of patients that will come to see us to do. Intrauterine inseminations. Right. Um, higher success rates, obviously when we're doing it this way. I think there's lots of reasons why an IUI would help you in this circumstance compared to just doing it at home. Um, we're setting you up for success on the back end. Yeah.'cause we're monitoring your cycle. We know exactly when you're gonna ovulate. So a lot of that, um. You know, stacking the deck in our favor, but also putting sperm up at the top of the uterus in the same way that we just described is gonna increase pregnancy rates for these patients as well. Um, a lot of times by the time same sex couples, for example, are coming to see me, they've already tried home insemination. Yeah. So it is kinda similar to trying. You know, intercourse at home, um, and then moving forward with I UIs. Yeah, absolutely. Well, one of the things that really has been surprising me lately is my patients have been sharing with me the cost of donor sperm. I mean, I, it used to be, I thought, around 600 to a thousand dollars. Okay? I've had some patients over the last week who told me they paid$2,500. I just looked at this. Today from Fairfax. Yeah. I'm like, what kind of donor do you have? I'm like, lemme see some pictures of this donor. I mean, this must have been a nice donor. My goodness. Yeah. Yeah. So when you're really making that investment with sperm, you want it to work, you wanna make sure it's put in at the right time as close to the egg or eggs as possible. You know, you really want to have the, the best chances there. So I think that's why a lot of people, um, decide to have a bit of assistance with that as well. Um, okay. Let me ask you a question. So sometimes when I'm doing an IUI, of course, the patient wants the very best chances it's gonna work, and so they tell me, Dr. Reed. I think I wanna do a double I. UI. So I wanted to get your thoughts on this. Do you, do you offer double IUI? Do you think it helps? Yeah. The way I approach this is kind of how I approach a lot of treatment options. What does the data show and then what's the risk versus benefits? Mm. Mm-hmm. So the data shows there's probably not much of a difference between doing a double IUI just simply means an IUI back to back days, right? Doing two versus one. So pregnancy rates are similar. Um, for patients who do two versus one IUI. But, you know, let's talk about what are the risks versus benefits. If there is any benefit for patients, the risk is really low. Mm-hmm. Right? Yeah. What are the downsides of it? The downsides that I count to my patient is you, you know, might have to miss school or work another day, right? To come in for an IUI. So it's more cumbersome and then it's an increased cost, right? So you're gonna double your cost of your IUI to some people. Those things aren't really important, and if they feel like there's any, you know, benefit to doing it, then why not? There's not really a risk. Yeah, right. There really isn't a big medical risk to doing two. Um, I really don't do a lot of double I UIs. I, I have had patients that, um, it's very important to them and that's how I counsel them. And I'm willing to do it, but it's not my standard. Yeah. And you know what? You kind of just made me think of something else too, which might make it more reasonable. Not even, so does it help our chances? But in a lot of our patients, we're really combining intercourse and IUI, right? But sometimes I have patients who can't have intercourse. Mm-hmm. Maybe that's the reason they're doing their IUI, which I guess we really, I should have added that in when we were talking about our other factors. Right. So why can they not have intercourse? Well, sometimes there are men who have trouble getting and maintaining an erection, or maybe they have trouble ejaculating during intercourse. Or sometimes they have patients that have a condition called vaginismus where they have so much pain or a lot of muscle spasms that they can't have intercourse. And so patients in that circumstance may feel like they're missing out.'cause they may say, well, if it's the average patient, they get to have intercourse these several days during the fertile period. Plus an IUI, but I only get to do the IUII feel like I'm missing out. So in that circumstance, could I consider doing a double IUI too? And you know, I think it could be reasonable in those circumstances. I don't think it's necessary, but, but I think it certainly could be reasonable. I understand the logic there. Yeah, yeah, sure. Um, okay. Have you heard of this device called, I don't know if I should say the name. Hopefully they're not gonna sue us or anything, but maybe I'll just say vaguely. It's a cervical cap. Mm-hmm. Okay. So it's kind of a do it yourself thing at home. Okay. It's a cervical cap and I. Your partner gives you your sperm sample and you put the sample in the cervical cap and then you put it in the vagina yourself and hold it up next to the cervix. Now I looked at their marketing because I thought it was interesting and they're claiming I think that it's just as effective as IUI, but when they give their IUI rates, they gave a very low number and I'm like. I, I'm like, I feel like it's deceptive in their marketing, um, when they described their results, uh, according, uh, or maybe compared to some other study that they found that had lower chances for success. So I would love to use that as their control. Anyone that's looking at IUI success rates, they find some study that has the lowest success rates for I UIs to show that their. Product is good. Right, exactly. And, and you know, because we have this, a marketer came too and tried to like, oh, compared to IUI rate of 6% and I said 6%. Yeah. And I'm like, whatcha talking about now? I guess that's a good point to bring up. What are chances of successful, uh, IUI, when you pair it with fertility medication, we are generally looking at about 15 to 20%. Each time you try. So I do always say it's good to mentally prepare yourself for the fact that, hey, this could take multiple cycles to have a good chance of it working. But when you look at the cumulative pregnancy rate after three cycles, some of that can add up and really give you a very reasonable chance of conceiving, especially if you're on the younger side. Yeah, absolutely. I touched my patient to my patients about cumulative success rate. Yeah. So going back to the cervical class. Yes, yes. It makes me laugh though, because okay, they're gonna take it, put it, and then. Pop it in there. Yeah. But you know, we know from studies that sperm are actually ejaculated. Yeah. Fast. They come out fast. Right. So I'm like, why not just have intercourse? Right. Where they can come out miles per hour. Right. You know you're gonna slow down. Yeah. As opposed to here, put it here in the slap. You gave them a rest stop. I know. Like logically to me, I'm like, I would want them coming out as quickly as possible. I like that it's, I haven't really thought about the velocity of sperm, but I think that's a good. Point, you don't really get the Oof Yeah. You get with intercourse. Yeah. Yeah. Um, so I, I can understand, um, for same-sex couples, single mothers by choice using donor sperm, you don't have the option to have intercourse. I do think that makes sense. Um, but if you truly have infertility, um. As we've been discussing, I don't think you should do it because first this cervical cap is still expensive. Mm-hmm. Okay. Um, and to me, you're just putting the sperm still down here in the vagina, right? You're not bypassing the mucus, you're not bypassing the cervix and, and, and all of this. So I don't really feel there's much benefit. Now, I'm sure a bunch of people are gonna be like, well, I got pregnant using it. Okay. I'm not saying it's impossible to get pregnant with it. Right. Again, everybody, even somebody not doing anything, has a 5% chance of getting pregnant every month, but I don't think it has as great of an efficiency as IUI has correct. Um, okay. I wanted to talk about people who are not a good candidate for IUI. So obviously you've heard me just rave about IUI and how much I love it, but certainly we get people who want to do IUI and I'm like, Hmm. Not the best option. Right, right. Absolutely. So we kind of mentioned in terms of male factor. Mm-hmm. What might be limiting there. So there's certain, um, concentrations of sperm if the sperm counts. Are just too low, right? Or when your parameters are too low, then you know, it's really not good to move forward with I UIs, not because it's impossible for them to work. Like we've said, just the likelihood of it working is lower and we might string you along for a longer period of time, and ultimately you may have to move forward with a higher level of treatment like IVF anyways. So we don't want to waste time and money, um, that you should have maybe been putting towards IVF. Yeah, absolutely. And I do think, um, maybe another population where I at least like to bring it up and talk about it is maybe late thirties, early forties, because can I help you get pregnant with IUI? Yes. But then are you gonna want more after that? Because if. So this might be our opportunity to consider doing IVF, not to necessarily get you pregnant in this moment, but to also have the opportunity to freeze embryos for later. Because once they're frozen, they're frozen in time. So even if you're older at that point. You may have a better chance at having a second, a third, or, or more children if we had taken the opportunity, um, to do that treatment, even if we didn't necessarily need the treatment at that time. Right. Um, the other thing that's really important is that your fallopian tubes need to be open. Yes. So, um, most of the time we're going to be doing tests. To make sure that both tubes or at least one tube is open. So we have to have that internal machinery working. Yeah, because we can't bypass the Philippine tubes when we're doing an IUI. So if your tubes are both blocked on both sides, then that is really an indication to proceed with IVF. Yeah. How many I UIs do you think somebody should try before you move on to IVF? So if they're not working, do you just keep trying or, or do you have kind of a number in mind where you're like, maybe we should move on to IVF? So I counsel my patients a lot about cumulative success rate, um, because what I really think is a challenge is sometimes people wanna do one IUI, right? Mm-hmm. People either fall into like, mm-hmm I want this one to work, or they want to do all. Bunch. Yeah. You know, there's really hardly any of these moderate patients. Yeah. Right. Yeah. But what the studies really tell us is that if you're gonna do I UIs, you really need to commit to giving it the good college try. Mm-hmm. Right? So I say, let's do at least three I UIs. Mm-hmm. Before we panic. Mm-hmm. Right? And say this treatment option isn't working for you. Let's explore something like IVF or higher level treatment options. Mm-hmm. Um, and I usually sit down after that. Three failed. I hate the word failed, but yeah. Unsuccessful iis and discuss what else could we do? Mm-hmm. What could we do differently? Do we need to pause and do some of this, um, more rare testing, investigation. Yeah. Um, and it doesn't mean that we can't do, you know, I UIs four or five and six. It just means we need to regroup, make sure we're not missing anything. And. Sitter, is this the right path for us to stay down certain couples? I'm definitely gonna encourage more so to move forward with IVF. Yeah. Versus other couples, I think, hey, it is really reasonable for you to try four, five, and six, for example, you know, maybe I have a sperm issue and a patient that's not ovulating. Yeah. It's really like the first time they're ever able to try. Yeah. Right, right. If someone hasn't been ovulating and the sperm counts haven't looked great when they've been trying at home on their own. They weren't really trying. Yeah. They didn't really have an opportunity each month. Yeah. So if you do three IUI, you know, rounds, that's like three months of trying. No one would give up after three months of trying. Yeah. You know, so I really try and gauge it towards what's the prognosis and the diagnosis of the couple itself. Um, if it, on the other hand is someone a couple. Unexplained fertility. Right. And they've been trying. Mm-hmm. And she's ovulating and the semen analysis looks normal and they tried already for over a year at home and we're still not having success. That might be someone that I'm worried there might be something else going on. Yeah, absolutely. Well, it sounds like you have a really personalized approach. Yeah. Which I think is great. I think some people just kind of have. Exact number in mind and they don't really customize it according to the patient. So I like that, how you really consider their history when you're thinking about that too. So, and then, okay, finally I wanted to talk about the cost of I ui. I think this is important to factor in. There's so many patients that don't really have much help from their insurance company, and I have so many people that come to see me for their new patient visit, and I do actually review costs with them and they are so relieved they say That's it. I thought IUI was gonna be thousands and thousands of dollars. And I say, well, IVF is, I'm like, IVF is like buying a car. Yeah. But I'm like, IUI treatment is so much more affordable. And so I thought I would just kind of quickly describe cost. Now my disclaimers are, this is one cost here, which may not be up. Maybe your clinic could be thousands of dollars, I dunno. Um, number two, it's cost this month, which is August. 2025 so it can change, right? Yeah. We never know when costs are gonna change and everything, but let's talk about somebody who has no insurance coverage at all. You are usually looking at doing two ultrasounds, a baseline ultrasound, and then a follow-up ultrasound to check for the follicles. And then the IUI. Each ultrasound is$250. The cost of the IUI is$500. The cost of the medications is usually less than a hundred. So when you put that all together, you're really looking at just a little over a thousand dollars to do an IUI cycle. I guess it is still expensive overall, right? But when you compare it to IVF, which is probably around$23,000 or so, um, it ends up being a treatment that is both more convenient because there's less appointments and uses less resources. Too. And so that's why I think it's definitely reasonable to give it a try sometimes before moving on to IBF. Totally. A couple things to consider in terms of cost too. Mm-hmm. Right. We just talked about cumulative success rates, so you really should think in your mind, okay, I'm committing to like at least$3,000 if we're gonna do this treatment. Um, and then Dr. Shelby Neil did a. Study looking at cost comparison with patients who, you know, proceeded immediately with going just to IVF, right? Mm-hmm. Um, or trying I UIs first and ultimately there can be some benefit to not doing I UIs. Mm-hmm. Right? And going straight to IVF because, um, patients who did explore IVF. First can have lower treatment cost overall. Why is that? Because if your I UIs are not gonna be successful, then you pay$3,000 and then you have to move forward with IVF. Mm-hmm. So it is something that I'm always straightforward with my patients about. Yeah. And you know, say there is always a chance that we might take you through these IUI treatments and we still have to pay for IVF later. Yeah. So cost is a really tricky. Thing to, yeah, really compare. Yeah. Right. Yeah. Um, but you're gonna be so happy if you do get pregnant off of Yeah. One of the first three I UIs. Yeah, absolutely. I think that's a really good point. Especially too, if you're talking about people who want to try more I UIs than the average person, right? Let's say they wanna do eight I UIs or something, right? Then we're talking$8,000 that you could have used towards an IVF cycle, right? So that's where it kind of becomes like, Hey, let's give you more of a natural chance with I ui. But also we don't wanna be waste. Full of resources either, so. Yeah, yeah, yeah. Okay, good. Well, I feel like we talked about a lot today. Are we ready to wrap it up? Yeah. Okay, perfect. Alright, we'll see you guys next week. Bye. Good